A mixed-methods longitudinal study of demoralization and depression in breast cancer survivors

BACKGROUND: Demoralization and depression are common among breast cancer survivors (BCS) following treatment. Although these conditions may be comorbid, their clinical distinctiveness highlights the need for deeper longitudinal and integrative examination. AIMS: This study examined longitudinal associations of demoralization and depression with selected psychological factors and their expression over time among BCS following treatment. METHODS: A mixed-methods longitudinal design was employed. Quantitatively, 190 BCS completed self-report measures at baseline (1-2 years postdiagnosis) and 6 months later. Linear mixed-effects models examined time-invariant and time-dependent associations. Qualitatively, 20 participants were interviewed in depth at both time points, and deductive, theory-driven thematic analysis was conducted. RESULTS: Quantitative analyses indicated that negative and positive self-compassion were associated with both demoralization and depression across time. Fear of recurrence was associated with demoralization across time, whereas its association with depression was primarily time-dependent. Qualitative findings revealed substantial heterogeneity and temporal complexity. At baseline, demoralization was marked by loss of the familiar self, diminished agency, and existential distress. Over time, participants followed divergent trajectories: Some experienced restoration of agency, meaning, and self-trust despite ongoing fear of recurrence, whereas others showed persistent or worsening depressive states characterized by resignation, isolation, and self-blame. Fear of recurrence was not uniformly destabilizing and became clinically salient primarily when accompanied by depression. CONCLUSIONS: Integrated findings suggest that demoralization and depression reflect distinct yet intersecting processes that vary over time. Differential assessment and interventions are essential. Demoralization may be best addressed through meaning-centered and identity-focused approaches, whereas depression may require mood-focused and behavioral interventions.